Healthcare Provider Details

I. General information

NPI: 1730740218
Provider Name (Legal Business Name): BAPTIST PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 RACETRACK RD NW
FORT WALTON BEACH FL
32547-1644
US

IV. Provider business mailing address

PO BOX 30532
PENSACOLA FL
32503-1532
US

V. Phone/Fax

Practice location:
  • Phone: 850-916-8700
  • Fax:
Mailing address:
  • Phone: 850-475-3726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: SHARON L CREECH
Title or Position: CREDENTIALS MANAGER
Credential:
Phone: 850-475-3726